1
|
Garton ALA, Oh SE, Müller A, Avadhani R, Zhang C, Merkler AE, Awad I, Hanley D, Kamel H, Ziai WC, Murthy SB. Catheter Tract Hemorrhages and Intracerebral Hemorrhage Outcomes in the Clot Lysis: Evaluating Accelerated Resolution of Intraventricular Hemorrhage Trial. Neurosurgery 2024; 94:334-339. [PMID: 37721435 DOI: 10.1227/neu.0000000000002687] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2023] [Accepted: 07/27/2023] [Indexed: 09/19/2023] Open
Abstract
BACKGROUND AND OBJECTIVES Factors associated with external ventricular catheter tract hemorrhage (CTH) are well studied; whether CTH adversely influence outcomes after intracerebral hemorrhage (sICH), however, is poorly understood. We therefore sought to evaluate the association between CTH and sICH outcomes. METHODS We performed a post hoc analysis of the Clot Lysis: Evaluating Accelerated Resolution of Intraventricular Hemorrhage trial. The exposure was CTH and evaluated on serial computed tomography scans between admission and randomization (approximately 72 hours). The primary outcomes were a composite of death or major disability (modified Rankin Score >3) and mortality alone, both assessed at 6 months. Secondary outcomes were functional outcomes at 30 days, permanent cerebrospinal fluid (CSF) shunt placement, any infection, and ventriculitis. We performed logistic regression adjusted for demographics, comorbidities, sICH characteristics, and treatment assignment, for all analyses. RESULTS Of the 500 patients included, the mean age was 59 (SD, ±11) years and 222 (44%) were female. CTH occurred in 112 (22.4%) patients and was more common in minority patients, those on prior antiplatelet therapy, and patients who had more than 1 external ventricular drain placed. The end of treatment intraventricular hemorrhage volume was higher among patients with CTH (11.7 vs 7.9 mL, P = .01), but there were no differences in other sICH characteristics or the total duration of external ventricular drain. In multivariable regression models, CTH was not associated with death or major disability (odds ratio, 0.7; 95% CI: 0.4-1.2) or death alone (odds ratio, 0.8; 95% CI, 0.5-1.4). There were no relationships between CTH and secondary outcomes including 30-day functional outcomes, permanent CSF shunt placement, any infection, or ventriculitis. CONCLUSION Among patients with sICH and large intraventricular hemorrhage, CTH was not associated with poor sICH outcomes, permanent CSF shunt placement, or infections. A more detailed cognitive evaluation is needed to inform about the role of CTH in sICH prognosis.
Collapse
Affiliation(s)
- Andrew L A Garton
- Department of Neurological Surgery, Weill Cornell Medicine, New York , New York , USA
| | - Stephanie E Oh
- Clinical and Translational Neuroscience Unit and Department of Neurology, Feil Family Brain and Mind Research Institute, Weill Cornell Medicine, New York , New York , USA
| | - Achim Müller
- Department of Neurology, Clinical Neuroscience Center, University Hospital Zurich and University of Zurich, Zurich , Switzerland
| | - Radhika Avadhani
- Brain Injury Outcomes Division, Johns Hopkins University School of Medicine, Baltimore , Maryland , USA
| | - Cenai Zhang
- Clinical and Translational Neuroscience Unit and Department of Neurology, Feil Family Brain and Mind Research Institute, Weill Cornell Medicine, New York , New York , USA
| | - Alexander E Merkler
- Clinical and Translational Neuroscience Unit and Department of Neurology, Feil Family Brain and Mind Research Institute, Weill Cornell Medicine, New York , New York , USA
| | - Issam Awad
- Department of Neurological Surgery, University of Chicago School of Medicine, Chicago , Illinois , USA
| | - Daniel Hanley
- Division of Neurosciences Critical Care, Department of Neurology, Johns Hopkins University School of Medicine, Baltimore , Maryland , USA
| | - Hooman Kamel
- Clinical and Translational Neuroscience Unit and Department of Neurology, Feil Family Brain and Mind Research Institute, Weill Cornell Medicine, New York , New York , USA
| | - Wendy C Ziai
- Brain Injury Outcomes Division, Johns Hopkins University School of Medicine, Baltimore , Maryland , USA
- Division of Neurosciences Critical Care, Department of Neurology, Johns Hopkins University School of Medicine, Baltimore , Maryland , USA
| | - Santosh B Murthy
- Clinical and Translational Neuroscience Unit and Department of Neurology, Feil Family Brain and Mind Research Institute, Weill Cornell Medicine, New York , New York , USA
| |
Collapse
|
2
|
Deng H, Puccio DJ, Anand SK, Yue JK, Hudson JS, Legarreta AD, Wei Z, Okonkwo DO, Puccio AM, Nwachuku EL. Power Drill Craniostomy for Bedside Intracranial Access in Traumatic Brain Injury Patients. Diagnostics (Basel) 2023; 13:2434. [PMID: 37510178 PMCID: PMC10378508 DOI: 10.3390/diagnostics13142434] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2023] [Revised: 07/16/2023] [Accepted: 07/18/2023] [Indexed: 07/30/2023] Open
Abstract
Invasive neuromonitoring is a bedrock procedure in neurosurgery and neurocritical care. Intracranial hypertension is a recognized emergency that can potentially lead to herniation, ischemia, and neurological decline. Over 50,000 external ventricular drains (EVDs) are performed in the United States annually for traumatic brain injuries (TBI), tumors, cerebrovascular hemorrhaging, and other causes. The technical challenge of a bedside ventriculostomy and/or parenchymal monitor placement may be increased by complex craniofacial trauma or brain swelling, which will decrease the tolerance of brain parenchyma to applied procedural force during a craniostomy. Herein, we report on the implementation and safety of a disposable power drill for bedside neurosurgical practices compared with the manual twist drill that is the current gold standard. Mechanical testing of the drill's stop extension (n = 8) was conducted through a calibrated tensile tester, simulating an axial plunging of 22.68 kilogram (kg) or 50 pounds of force (lbf) and measuring the strength-responsive displacement. The mean displacement following compression was 0.18 ± 0.11 mm (range of 0.03 mm to 0.34 mm). An overall cost analysis was calculated based on the annual institutional pricing, with an estimated $64.90 per unit increase in the cost of the disposable electric drill. Power drill craniostomies were utilized in a total of 34 adult patients, with a median Glasgow Coma Scale (GCS) score of six. Twenty-seven patients were male, with a mean age of 50.7 years old. The two most common injury mechanisms were falls and motor vehicle/motorcycle accidents. EVDs were placed in all subjects, and additional quad-lumen neuromonitoring was applied to 23 patients, with no incidents of plunging events or malfunctions. One patient developed an intracranial infection and another had intraparenchymal tract hemorrhaging. Two illustrative TBI cases with concomitant craniofacial trauma were provided. The disposable power drill was successfully implemented as an option for bedside ventriculostomies and had an acceptable safety profile.
Collapse
Affiliation(s)
- Hansen Deng
- Department of Neurological Surgery, University of Pittsburgh Medical Center, 200 Lothrop Street, Suite B-400, Pittsburgh, PA 15213, USA
| | - David J Puccio
- Department of Neurological Surgery, University of Pittsburgh Medical Center, 200 Lothrop Street, Suite B-400, Pittsburgh, PA 15213, USA
| | - Sharath K Anand
- Department of Neurological Surgery, University of Pittsburgh Medical Center, 200 Lothrop Street, Suite B-400, Pittsburgh, PA 15213, USA
| | - John K Yue
- Department of Neurological Surgery, University of California San Francisco, San Francisco, CA 94110, USA
| | - Joseph S Hudson
- Department of Neurological Surgery, University of Pittsburgh Medical Center, 200 Lothrop Street, Suite B-400, Pittsburgh, PA 15213, USA
| | - Andrew D Legarreta
- Department of Neurological Surgery, University of Pittsburgh Medical Center, 200 Lothrop Street, Suite B-400, Pittsburgh, PA 15213, USA
| | - Zhishuo Wei
- Department of Neurological Surgery, University of Pittsburgh Medical Center, 200 Lothrop Street, Suite B-400, Pittsburgh, PA 15213, USA
| | - David O Okonkwo
- Department of Neurological Surgery, University of Pittsburgh Medical Center, 200 Lothrop Street, Suite B-400, Pittsburgh, PA 15213, USA
| | - Ava M Puccio
- Department of Neurological Surgery, University of Pittsburgh Medical Center, 200 Lothrop Street, Suite B-400, Pittsburgh, PA 15213, USA
| | - Enyinna L Nwachuku
- Department of Neurological Surgery, Cleveland Clinic Foundation, Cleveland, OH 44195, USA
| |
Collapse
|
3
|
Mahto N, Owodunni OP, Okakpu U, Kazim SF, Varela S, Varela Y, Garcia J, Alunday R, Schmidt MH, Bowers CA. Postprocedural Complications of External Ventricular Drains: A Meta-Analysis Evaluating the Absolute Risk of Hemorrhages, Infections, and Revisions. World Neurosurg 2023; 171:41-64. [PMID: 36470560 DOI: 10.1016/j.wneu.2022.11.134] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2022] [Accepted: 11/29/2022] [Indexed: 12/09/2022]
Abstract
BACKGROUND External ventricular drain (EVD) insertion is often a lifesaving procedure frequently used in neurosurgical emergencies. It is routinely done at the bedside in the neurocritical care unit or in the emergency room. However, there are infectious and noninfectious complications associated with this procedure. This meta-analysis sought to evaluate the absolute risk associated with EVD hemorrhages, infections, and revisions. The secondary purpose was to identify and characterize risk factors for EVD complications. METHODS We searched the MEDLINE (PubMed) database for "external ventricular drain," "external ventricular drain" + "complications" or "Hemorrhage" or "Infection" or "Revision" irrespective of publication year. Estimates from individual studies were combined using a random effects model, and 95% confidence intervals (CIs) were calculated with maximum likelihood specification. To investigate heterogeneity, the t2 and I2 tests were utilized. To evaluate for publication bias, a funnel plot was developed. RESULTS There were 260 total studies screened from our PubMed literature database search, with 176 studies selected for full-text review, and all of these 176 studies were included in the meta-analysis as they met the inclusion criteria. A total of 132,128 EVD insertions were reported, with a total of 130,609 participants having at least one EVD inserted. The pooled absolute risk (risk difference) and percentage of the total variability due to true heterogeneity (I2) for hemorrhagic complication was 1236/10,203 (risk difference: -0.63; 95% CI: -0.66 to -0.60; I2: 97.8%), infectious complication was 7278/125,909 (risk difference: -0.65; 95% CI: -0.67 to -0.64; I2: 99.7%), and EVD revision was 674/4416 (risk difference: -0.58; 95% CI: -0.65 to -0.51; I2: 98.5%). On funnel plot analysis, we had a variety of symmetrical plots, and asymmetrical plots, suggesting no bias in larger studies, and the lack of positive effects/methodological quality in smaller studies. CONCLUSIONS In conclusion, these findings provide valuable information regarding the safety of one of the most important and most common neurosurgical procedures, EVD insertion. Implementing best-practice standards is recommended in order to reduce EVD-related complications. There is a need for more in-depth research into the independent risk factors associated with these complications, as well as confirmation of these findings by well-structured prospective studies.
Collapse
Affiliation(s)
- Neil Mahto
- Department of Neurosurgery, University of New Mexico Hospital, Albuquerque, New Mexico, USA
| | - Oluwafemi P Owodunni
- Department of Neurosurgery, University of New Mexico Hospital, Albuquerque, New Mexico, USA
| | - Uchenna Okakpu
- West Virginia University School of Medicine, Morgantown, West Virginia, USA
| | - Syed F Kazim
- Department of Neurosurgery, University of New Mexico Hospital, Albuquerque, New Mexico, USA
| | - Samantha Varela
- Department of Neurosurgery, University of New Mexico Hospital, Albuquerque, New Mexico, USA
| | - Yandry Varela
- Burrell College of Osteopathic Medicine, New Mexico, USA
| | - Josiel Garcia
- Burrell College of Osteopathic Medicine, New Mexico, USA
| | - Robert Alunday
- Department of Neurosurgery, University of New Mexico Hospital, Albuquerque, New Mexico, USA
| | - Meic H Schmidt
- Department of Neurosurgery, University of New Mexico Hospital, Albuquerque, New Mexico, USA
| | - Christian A Bowers
- Department of Neurosurgery, University of New Mexico Hospital, Albuquerque, New Mexico, USA.
| |
Collapse
|
4
|
Xu FWX, Lim NA, Sim MA, Lean LL, Loh NHW, Ng KT, Chua VTY, Chew STH, Ti LK. Point-of-care platelet function testing for guided transfusion in neurosurgical management of intracranial hemorrhage: a systematic review. Eur J Med Res 2022; 27:191. [PMID: 36182926 PMCID: PMC9526957 DOI: 10.1186/s40001-022-00819-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2022] [Accepted: 09/06/2022] [Indexed: 11/14/2022] Open
Abstract
Given the rising prevalence of antiplatelet therapy, rapid preoperative identification of patients with bleeding diathesis is necessary for the guidance of blood product administration. This is especially relevant in neurosurgery for intracranial hemorrhage (ICH), where indiscriminate transfusions may lead to further hemorrhagic or thromboembolic injury. Point-of-care (POC) testing of platelet function is a promising solution to this dilemma, as it has been proven effective in cardiac surgery. However, to date, POC platelet function testing in neurosurgery has not been extensively evaluated. This systematic review appraises the use of POC platelet function test (PFT) in emergency neurosurgery in terms of its impact on patient outcomes. A comprehensive search was conducted on four electronic databases (Pubmed, MEDLINE, Embase, and Cochrane) for relevant English language articles from their respective inceptions until 1 June 2022. We included all randomized controlled trials and cohort studies that met the following inclusion criteria: (i) involved adult patients undergoing neurosurgery for ICH; (ii) evaluated platelet function via POC PFT; (iii) reported a change in perioperative blood loss; and/or (iv) reported data on treatment-related adverse events and mortality. Assessment of study quality was conducted using the Newcastle Ottawa Quality Assessment Scale for Cohort Studies and Case–Control Studies, and the JBI Critical Appraisal Checklist for Case Series. The search yielded 2,835 studies, of which seven observational studies comprising 849 patients met the inclusion criteria for this review. Overall, there is evidence that the use of POC PFT to assess bleeding risk reduced bleeding events, thromboembolic adverse outcomes, and the length of hospitalization. However, there is currently insufficient evidence to suggest that using POC PFT improves blood product use, functional outcomes or mortality.
Collapse
Affiliation(s)
- Flora Wen Xin Xu
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Nicole-Ann Lim
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Ming Ann Sim
- Department of Anesthesia, Singapore General Hospital, Singapore, Singapore
| | - Lyn Li Lean
- Department of Anesthesia, Ng Teng Fong General Hospital, Singapore, Singapore
| | - Ne-Hooi Will Loh
- Department of Anesthesia, National University Hospital, Singapore, Singapore
| | - Ka Ting Ng
- Department of Anesthesiology, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Vanessa Tze Yuh Chua
- Department of Anesthesia, Singapore General Hospital, Singapore, Singapore.,Department of Anesthesia, National University Hospital, Singapore, Singapore
| | | | - Lian Kah Ti
- Department of Anesthesia, National University Hospital, Singapore, Singapore. .,Department of Anesthesia, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore.
| |
Collapse
|
5
|
Pease M, Nwachuku E, Goldschmidt E, Elmer J, Okonkwo DO. Complications from Multimodal Monitoring Do not Affect Long-Term Outcomes in Severe Traumatic Brain Injury. World Neurosurg 2022; 161:e109-e117. [PMID: 35077890 PMCID: PMC9081234 DOI: 10.1016/j.wneu.2022.01.059] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2021] [Revised: 01/13/2022] [Accepted: 01/15/2022] [Indexed: 10/19/2022]
Abstract
BACKGROUND Invasive neuromonitoring is a mainstay of modern management of severe traumatic brain injury (TBI). Complication rates of neuromonitor placement are widely reported, but their effects on long-term outcomes are less studied. We evaluated the association of neuromonitor complications on long-term outcomes in a prospective severe TBI cohort. METHODS We reviewed 599 patients with severe TBI from November 2002 through 2018 for neuromonitor-associated hemorrhage and infection. We compared outcome differences between patients with and without neuromonitoring-associated complications using the Glasgow Outcomes Scale (GOS) at 3, 6, 12, and 24 months post trauma. When analyzing neuromonitoring infections, we removed all patients who expired before discharge as early mortality was associated with reduced infection rates. RESULTS Neuromonitor-associated hemorrhage occurred in 62 out of 534 patients with post placement imaging (11.6%) and was increased in patinets who underwent a craniotomy (24% vs. 11%, P = 0.005). Clinical outcomes did not differ in patients with neuromonitor-associated hemorrhage. Neuromonitor-associated infection occurred in 30 of 389 patients (7.7%) who survived to discharge. Infection was associated with worse outcomes at 3 months (P = 0.03), where the proportion of patients with favorable outcomes (P = 0.02) was decreased despite similar mortality (P = 0.24). Patients with an infection recovered by 6 months, at which point there were no differences in total GOS or rates of favorable outcomes then or at later time points (P > 0.26). Neuromonitor-associated infection was associated with increased length of stay (P = 0.01) and depressed skull fractures (P = 0.03) but did not affect rates of shunting (P = 0.99). CONCLUSIONS Complications of neuromonitoring in severe TBI are associated with delayed recovery but not long-term outcomes.
Collapse
Affiliation(s)
- Matthew Pease
- Department of Neurosurgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA.
| | - Enyinna Nwachuku
- Department of Neurosurgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Ezequiel Goldschmidt
- Department of Neurosurgery, University of California, San Francisco, California, USA
| | - Jonathan Elmer
- Department of Emergency Medicine, Critical Care Medicine, and Neurology, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - David O Okonkwo
- Department of Neurosurgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| |
Collapse
|
6
|
Evans D, Flood R, Davies O, Wareham J, Mortimer A. Impact of Intravenous Aspirin Administration on Ventriculostomy-Associated Hemorrhage in Coiled Acute Subarachnoid Hemorrhage Patients. Neurointervention 2021; 16:141-148. [PMID: 34162195 PMCID: PMC8261103 DOI: 10.5469/neuroint.2021.00150] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2021] [Accepted: 06/15/2021] [Indexed: 11/24/2022] Open
Abstract
Purpose Aspirin has beneficial effects on coiling, even in acute subarachnoid hemorrhage, but there is also a perceived risk of increased bleeding and, importantly, a concern regarding ventriculostomy-associated hemorrhage (VAH) in those with complicating hydrocephalus. We aimed to assess the rate and extent of VAH in patients specifically treated with procedural intravenous aspirin during endovascular coiling of ruptured intracranial aneurysms. Materials and Methods This was a single neurovascular center retrospective observational study of consecutive patients treated over a three-year period. The rate of VAH assessed using computed tomography and clinical outcomes were compared in patients receiving intraprocedural intravenous aspirin loading (n=90) versus those that did not receive the drug (n=40). Results There was a significantly elevated rate of VAH in patients receiving intravenous aspirin (30% vs. 2.5%, odds ratio 16.7 [95% confidence interval: 2.2–128.0], P<0.0001). The majority of VAH was <10 mm in size (70%) with the largest bleed measuring 20 mm. No hematoma required surgical evacuation. No difference in favorable outcome at discharge was demonstrated. There was no difference in mortality between the 2 groups. Conclusion Loading with intravenous aspirin during endovascular treatment of ruptured intracranial aneurysms significantly increases the risk of VAH, but most are small with minimal impact on clinical outcome at discharge. Intravenous aspirin should probably be reserved for selected cases but should not be withheld based on risk of VAH.
Collapse
Affiliation(s)
- David Evans
- Department of Neuroradiology, North Bristol NHS Trust, Bristol, UK
| | - Richard Flood
- Department of Neuroradiology, North Bristol NHS Trust, Bristol, UK
| | - Owain Davies
- Department of Neurosurgery, North Bristol NHS Trust, Bristol, UK
| | - James Wareham
- Department of Neuroradiology, North Bristol NHS Trust, Bristol, UK
| | - Alex Mortimer
- Department of Neuroradiology, North Bristol NHS Trust, Bristol, UK
| |
Collapse
|
7
|
Qin G, Pang G, Zhong S, Chen H, Tang X, Lan S. Increased risk of Ventriculostomy-Associated hemorrhage in patients treated with antiplatelet agents for stent-assisted coiling of ruptured intracranial aneurysms. Br J Neurosurg 2020; 35:270-274. [PMID: 32643426 DOI: 10.1080/02688697.2020.1787338] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
PURPOSE The aim of this study is to evaluate the impact of antiplatelet agents for stent-assisted coiling, including intravenous (IV) tirofiban as an antiplatelet premedication, on rates of external ventricular drain (EVD)-related hemorrhage in acutely ruptured intracranial aneurysms. The impact of IV tirofiban in particular was also evaluated. METHODS Rates of radiographically identified hemorrhage associated with EVD placement were compared between patients who received an antiplatelet agent for stent-assisted coil embolization (SACE), and patients who did not receive an antiplatelet agent between June 2013 and June 2019. RESULTS 78 patients treated for a ruptured aneurysm which required an EVD were included. A total of 46 patients who underwent stent-assisted coiling and received IV tirofiban and oral asipirin and clopidogrel (DAPT) were included in the antiplatelet group, while 32 who underwent single coiling and received no antiplatelet therapy were included in the control group. Overall, EVD-related hemorrhage occurred in 13 patients (16.67%): 11 (23.91%) in the antiplatelet group and 2 (6.25%) in the control group (p = 0.040). Of 37 patients who underwent computed tomography after SACE, but before the use of DAPT, 8 (21.62%) exhibited EVD-related hemorrhage after IV tirofiban therapy (p = 0.070 vs. control group). EVD-related hemorrhage was not significantly different between patients with EVD placement after coil embolization versus before coil embolization (p = 0.124). In the subgroup analysis for the antiplatelet group, we did not observed increased EVD-related hemorrhage in patients receiving EVD placement after administration of antiplatelet agents (8/27 [29.63%]) versus before administration of antiplatelet agents (3/19 [15.79%]). CONCLUSION Patients with ruptured aneurysm who receive an antiplatelet agent for stent-assisted coiling are at a higher risk for EVD-related hemorrhage. The order of EVD placement and EVT, as well as the order of EVD placement and antiplatelet initiation do not appear to be significantly different regarding the outcome of EVD-related hemorrhage.HighlightsPatients with ruptured aneurysm who receive an antiplatelet agent for stent-assisted coiling are at a higher risk for EVD-related hemorrhage.There was a trend towards higher EVD related haemorrhage when tirofiban was used but it did not reach statisitical significance.The order of EVD-whether before vs after endovascular treatment, or before vs after antiplatelet therapy did not influence the EVD-related hemorrhage rates.
Collapse
Affiliation(s)
- Guowen Qin
- Department of Neurosurgery, People's Hospital of Guangxi Zhuang Autonomous Region, Nanning, China
| | - Gang Pang
- Department of Neurosurgery, People's Hospital of Guangxi Zhuang Autonomous Region, Nanning, China
| | - Shu Zhong
- Department of Neurosurgery, People's Hospital of Guangxi Zhuang Autonomous Region, Nanning, China
| | - Haijun Chen
- Department of Neurosurgery, People's Hospital of Guangxi Zhuang Autonomous Region, Nanning, China
| | - Xihe Tang
- Department of Neurosurgery, People's Hospital of Guangxi Zhuang Autonomous Region, Nanning, China
| | - Shengyong Lan
- Department of Neurosurgery, People's Hospital of Guangxi Zhuang Autonomous Region, Nanning, China
| |
Collapse
|
8
|
Woo PYM, Ng BCF, Xiao JX, Wong D, Seto A, Lam S, Yim C, Lo HY, Po YC, Wong LYW, Lee MWY, Yam KY, Pu JKS, Chan KY, Poon WS. The importance of aspirin, catheterization accuracy, and catheter design in external ventricular drainage-related hemorrhage: a multicenter study of 1002 procedures. Acta Neurochir (Wien) 2019; 161:1623-1632. [PMID: 31222516 DOI: 10.1007/s00701-019-03978-2] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2019] [Accepted: 06/05/2019] [Indexed: 11/25/2022]
Abstract
BACKGROUND External ventricular drainage (EVD) is the commonest neurosurgical procedure performed in daily neurosurgical practice, but relatively few studies have investigated the incidence and risk factors of its related hemorrhagic complications. METHODS This was a multicenter retrospective review of consecutive EVD procedures. Patients 18 years or older who underwent EVD and had a routine postoperative computed tomography (CT) scan performed within 24 hours were included. EVD-related hemorrhage was defined as new intracranial hemorrhage immediately adjacent or within the ventricular catheter trajectory. The volume of hemorrhage and the position of the catheter tip were assessed. A review of patient-, disease-, and surgery-related factors including the ventricular catheter design utilized was conducted. The Bonferroni correction was applied to the alpha level of significance (0.05) for multivariable analysis. RESULTS Nine hundred sixty-two patients underwent 1002 EVD performed by neurosurgeons in the operating theater. Sixteen percent (154) of patients were on aspirin before the procedure. Thirty-four percent (333) of patients had intracerebral hemorrhage, 25% (251) had aneurysmal subarachnoid hemorrhage and 16% (158) had traumatic brain injury. The mean duration from EVD to the first postoperative CT scan was 20 ± 4 h. EVD-related hematomas were detected after 81 procedures with a per-catheter risk of 8.1%. Mean hematoma volume was 1.2 ± 3.3 ml. Most were less than 1 ml (grade I, 79%, 64), 1 to 15 ml (grade II) in 20% (16) and a single clot larger than 15 ml (grade III, 1%) were detected. Clinically significant hemorrhage that resulted in catheter occlusion occurred in 1.7% (17) of procedures. Most catheters (62%, 625) were optimally placed, i.e., its tip being within the ipsilateral frontal horn or third ventricle. Three non-antibiotic-impregnated ventricular catheter designs were used with 55% (550) being the 2.2-mm Integra™ catheter, 14% (137) being the 2.8-mm Medtronic™ catheter, and 31% (315) being the 3.1-mm Codman™ catheter. Independent significant predictors for EVD-related hemorrhage were the preoperative prescription of aspirin (adjusted OR 1.94; 95% CI 1.10-3.44), catheter malposition (aOR 1.99; 95% CI 1.22-3.23), and use of the 2.8-mm Medtronic™ catheter (aOR 4.22; 95% CI 2.39-7.41). CONCLUSIONS The per-catheter risk of hemorrhage was 8.1%, but the incidence of symptomatic hemorrhage was low. The only patient risk factor was aspirin intake. This is the first study to evaluate and establish an association between catheter malposition and catheter design with EVD-related hemorrhage.
Collapse
Affiliation(s)
- Peter Y M Woo
- Department of Neurosurgery, Kwong Wah Hospital, Hong Kong, China.
| | - Ben C F Ng
- Department of Neurosurgery, Queen Elizabeth Hospital, Hong Kong, China
| | - Jacob X Xiao
- Department of Neurosurgery, Kwong Wah Hospital, Hong Kong, China
| | - Daniel Wong
- Department of Neurosurgery, Kwong Wah Hospital, Hong Kong, China
| | - Andrew Seto
- Department of Neurosurgery, Kwong Wah Hospital, Hong Kong, China
| | - Sandy Lam
- Department of Neurosurgery, Kwong Wah Hospital, Hong Kong, China
| | - Carmen Yim
- Department of Neurosurgery, Kwong Wah Hospital, Hong Kong, China
| | - Hong-Yip Lo
- Department of Neurosurgery, Kwong Wah Hospital, Hong Kong, China
| | - Yin-Chung Po
- Department of Neurosurgery, Princess Margaret Hospital, Hong Kong, China
| | - Larry Y W Wong
- Department of Neurosurgery, Queen Elizabeth Hospital, Hong Kong, China
| | - Michael W Y Lee
- Department of Neurosurgery, Pamela Youde Nethersole Eastern Hospital, Hong Kong, China
| | - Kwong-Yui Yam
- Department of Neurosurgery, Tuen Mun Hospital, Hong Kong, China
| | - Jenny K S Pu
- Division of Neurosurgery, Department of Surgery, Queen Mary Hospital, Hong Kong, China
| | - Kwong-Yau Chan
- Department of Neurosurgery, Kwong Wah Hospital, Hong Kong, China
| | - Wai-Sang Poon
- Division of Neurosurgery, Department of Surgery, Prince of Wales Hospital, Hong Kong, China
| |
Collapse
|